Passmedicine Flashcards
What is group B strep also known as?
Streptococcus agalactiae
What is the prophylaxis given to mothers for group B strep?
Intrapartum IV benzylpenicillin (during delivery).
When should mothers be given prophylaxis for group B strep?
- If GBS has been detected in a previous pregnancy - mothers can have prophylaxis OR can be offered testing in late pregnancy then abx if still positive.
- Previous baby with early or late onset GBS disease
- Preterm labour
- Pyrexia >38 during labour
If women are tested for GBS when should it be done?
35-37 weeks
OR
3-5 weeks prior to delivery date
If you have had GBS detected in a previous pregnancy, what’s the chance of developing it again?
50%
What are the UKMEC 3 conditions for COCP?
- > 35 years and smoking <15 per day
- BMI >35
- Family history of VTE in first degree relatives <45 years
- Controlled hypertension
- Immobility (wheelchair)
- Carrier of BRCA1/BRCA2
- Current gallbladder disease
What are UKMEC4 conditions for COCP?
- > 35 years and smoking >15 per day
- Migraine with aura
- History of thromboembolic disease or thromboembolic mutation
- History of stroke or IDH
- Breast feeding < 6 weeks post party
- Uncontrolled hypertension
- Current breast cancer
- Major surgery with prolonged immobilisation
- Positive antiphospholipid antibodies (SLE)
When should the COCP be stopped and started regarding surgery?
Should be stopped 4 weeks before
Restarted 2 weeks after
What is HELLP syndrome?
- Haemolysis
- Elevated liver enzymes
- Low platelets
What is the definition of pre-eclampsia?
New onset HTN >140/90 after 20 weeks of pregnancy
AND 1 or more of:
- proteinuria
- other organ involvement (kidney insufficiency, liver, neurological, haematological, uteroplacental dysfunction)
When are women with pre eclampsia likely to be admitted to hospital?
If they have a blood pressure >160/110
What is placental abruption?
Separation of a normally sited placental from the uterine wall - resulting in maternal haemorrhage into the intervening space.
What are the clinical features of placental abruption?
- Shock out of keeping with visible loss
- Constant pain
- Tender tense uterus
- Normal lie and presentation
- Foetal heart absent or distressed
- Woody hard uterus (because the blood fills the myometrium)
What is the time until effective for different contraceptives?
If not first day of period
Immediately - IUD
2 days - POP
7 days - COCP, injection, IUS
When can different contraceptives be started after pregnancy?
IUS and IUD - within 48 hours OR after 4 weeks
POP - Any time
COCP - after 21 days (CI in women <6 weeks post parum and breastfeeding)
What is an amniotic fluid embolism?
When foetal cells or amniotic fluid enters the mothers bloodstream and stimulates a reaction.
Usually occurs during labour or within 30 minutes after.
What are the symptoms of an amniotic fluid embolism?
Chills, shivering, sweating, anxiety, coughing.
Cyanosis, hypotension, bronchospasm, tachycardia, arrhythmia, MI.
What is the management of preterm pre labour rupture of membranes?
Admission
IM corticosteroids (stimulates surfactant)
Oral erythromycin for 10 days
In preterm pre labour rupture of membranes when should delivery be considered?
At 34 weeks gestation
What are the physiological changes of blood in pregnancy?
Reduced urea
Reduced creatinine
Increased urinary protein loss
What are the rules regarding levonorgestrel?
- Dose = 1.5mg
- Must be taken within 72 hrs after UPSI
- Double dose for BMI > 26 or weight >70kg
- Repeat dose if vomiting within 3 hours of taking tablet
- Can commence hormonal contraception immediately after
- Can be used more than once in one menstrual cycle
What are the rules regarding ulipristal?
- Dose = 30mg
- Must be taken within 120 hours of UPSI
- Contraception MUST be stopped until 5 days after taking it
- Barrier contraception must be used in between times
- Caution in patients with severe asthma
- Can be used more than once in one menstrual cycle
- Breast feeding must be stopped for 1 week after §
What are the rules regarding IUD when used as emergency contraception?
- Must be inserted within 5 days of UPSI OR within 5 days after the likely ovulation date
- Can be left in long term, if being removed, patient MUST wait until the next period
What is the most common cause of post menopausal bleeding?
Vaginal atrophy
Usually also causes pain during sex or dryness and post coital bleeding.
What are the characteristics of baby blues?
- seen in 60-70% of women
- seen 3-7 days after birth
- more common in primps
- reassurance and health visitor support is key
What are the characteristics of postnatal depression?
- seen in 10% of women
- start within a month and peak at 3 months
What antidepressants are used in post natal depression?
Paroxetine or sertraline
Fluoxetine is avoided due to a long half life
What is the Amsels criteria for bacterial diagnosis?
3 of the 4:
- Thin, white, homogenous discharge
- Clue cells on microscopy
- Vaginal pH >4.5
- Positive Whiff test (addition of potassium hydroxide results in fishy odour)
What is the treatment for gonorrhoea?
Single dose of IM Ceftriazone
What are the signs of trichomonad vaginalis?
- Strawberry cervix with exudation
- Offensive, musty, frothy green vaginal discharge
What are the signs of vaginal candidiasis (thrush)?
- Caused by Candida albicans
- Cottage cheese
- No offensive discharge
- Vulvitis - dysparenuria, dysuria
- Itch
- Vulval erythema, fissuring, satellite lesions
What is the treatment for vaginal candidiasis?
Oral fluxonazole 150mg as a single dose
What fluids are given to women admitted with hyperemesis gravidarum?
IV normal saline with potassium chloride (hypokalaemia is common)
When should women with vomiting during pregnancy be admitted to hospital?
- A confirmed or suspected comorbidity
- Continued nausea and vomiting - unable to keep down liquids or oral antiemetics
- Continued nausea and vomiting - ketonuria and/or weight loss (greater than 5%) despite treatment with oral antiemetics
What is the criteria for hyperemesis gravidarum?
- Weight loss of 5% of pre pregnancy weight
- Dehydration
- Electrolyte imbalance
What is the treatment of hyperemesis gravidarum?
First line:
- Oral cyclising, promethazine, prochlorperazine or chlorpromazine
Second line:
- Oral ondansetron (associated with cleft lip if used in first trimester)
What is the treatment for stress incontinence?
- Pelvic floor exercises (minimum of 3 months)
- Surgical procedures (retropubic mid-urethral tape)
- Medication - Duloxetine
What is the treatment for urge incontinence/overactive bladder?
- Bladder retraining (minimum 6 weeks)
- Anticholinergics - Oxybutinin, tolterodine, darifenacin
- Mirabegron - in frail elderly patients (Don’t use anticholinergics)
What are the classifications of perineal tears?
1st degree:
- superficial damage with no muscle involvement
- Do not require repair
2nd degree:
- Injury to the perineal muscle but NOT anal sphincter
- Suturing on the ward by midwife or clinician
3rd degree:
- injury to perineum involving anal sphincter complex (external anal sphincter and internal anal sphincter)
- 3a = <50% of EAS torn
- 3b = >50% of EAS torn
- 3c = IAS torn
- requires repair in theatre by clinician
4th degree:
- injury to perineum involving EAS, IAS and rectal mucosa
- requires repair in theatre
What is the initial management for chickenpox exposure in pregnancy?
If any doubt as to previous infection, maternal blood should be checked for varicella antibodies.
What should be given if a pregnant women <20 wks gestation is in contact with chickenpox and is not immune?
Varicella-zoster immunoglobulin
Effective up to 10 days post exposure
What should be done if pregnant women is not immune to chicken pox and is >20 weeks?
Treatment should be given 7-14 days after exposure:
Varicella-zoster immunoglobulin (VZIG)
OR
antivirals (acyclovir or valaciclovir)
What should be done if a pregnant women develops chicken pox?
< 20 weeks - oral acyclovir
> 20 weeks - oral acyclovir if within 24 hrs of a rash
What is placenta previa?
A placenta lying wholly or partially in the lower uterine segment
What are the signs of placenta previa?
No pain
No tenderness of uterus
Shock in proportion to visible loss
Foetal heart usually normal
What tests SHOULD and SHOULDNT be done in suspected placenta previa?
Gold standard - Transvaginal ultrasound
Contraindicated - Speculum or digital vaginal examination
When does ovulation occur?
14 days before your next period (subtract 14 from the number of days of your cycle)
Serum progesterone is measured 7 days before the end of a women cycle - give the best measure of ovulation because serum progesterone is at its highest 7 days before next period
When should external cephalic version be carried out?
36 weeks in nulliparous women
37 weeks in multiparous women
What is the treatment for menorrhagia?
Does not require contraception:
- NSAIDs - Mefenamic acid (500mg tds)
- Tranexamic acid (1g tds)
Requires contraception:
- First line - IUS mirena coil
- COCP
- Long acting progesterones (depo-proverb)
What is a category 1 cesarian section and when should it be done?
Within 30 minutes of the decision
An immediate threat to life of mother or baby: Uterine rupture, placental abruption, cord prolapse, foetal hypoxia, foetal bradycardia
What is a category 2 cesarian section and when should it be done?
Within 75 minutes of the decision
Maternal or fetal compromise which is not immediately life threatening
What is a category 3 and 4 cesarean section?
3 - delivery is required but mother and baby are stable
4 - Elective cesarean section
What is the management of gestational diabetes?
- If fasting plasma glucose <7mmol a trial of diet and exercise should be offered - if this doesn’t work start metformin - if it doesn’t work then SHORT ACTING insulin should be tried
- If fasting plasma glucose >7mmol - insulin should be started
When might induction of pregnancy be indicated?
- Prolonged pregnancy (1-2 weeks after estimated delivery date)
- Prelabour premature rupture of membranes
- Diabetic mother >38 weeks
- Pre eclampsia
- obstetric cholestasis
- Intrauterine death
What score is used to determine whether induction of labour should be done?
Bishop score:
< 5 = labour is unlikely to start without induction
>8 = There is a high chance of spontaneous labour or a good response to interventions made to induce labour
What things can be done to induce labour?
- Membrane sweep
- Separates the chorionic membrane from the uterus
- Done by midwife at antenatal clinic
- Offered to nulliparous women at 40 and 41 week visit
- Offered to porous women at 41 week visit - Vaginal prostaglandin (E2)
- Oral prostaglandin E1 (Misoprostol)
- Maternal oxytocin infusion
- Amniotomy (breaking of waters)
- Cervical ripening balloon
When should each method of induction be used?
Bishop score <6:
- vaginal prostaglandin or misoprostol
- balloon catheter can be considered
Bishop score >6:
- Amniotomy and IV oxytocin infusion
At what age are children unable to consent to sexual intercourse?
< 13 - child protection measures should always be sought
What is the pathway for cervical screening?
Cervical sweep:
- HPV negative - re sweep in 5 years
- HPV positive - examined by cytology
Cytology:
1. If cytology is abnormal - refer for colposcopy.
2. If cytology is negative - repeat sweep in 12 months.
3. If after 12 months HPV is negative - return to normal recall.
4. If HPV is still positive and cytology still normal - repeat in 12 months.
5. If HPV is negative after 24 months - return to normal recall
6. If HPV is positive at 24 months - refer for colposcopy
If inadequate sample - repeat sample within 3 months
If two consecutive inadequate samples - colposcopy
Where is the most common and most dangerous place to have an ectopic pregnancy?
97% are tubal - in the ampulla
Most likely to rupture if in the isthmus
When is prophylactic anti-D given routinely to Rhesus negative women in pregnancy?
At 28 and 34 weeks.
When is the copper coil contraindicated?
In women with suspected sexually transmitted infection.
In women with pelvic inflammatory disease.
Which cancers are the COCP protective and increased risk of?
- Increased risk of breast and cervical cancer
- Protective against ovarian and endometrial cancer
When should the initial booking visit with the midwife be?
8 - 12 weeks
When does downs syndrome with nuchal screening occur?
11-13+6 weeks
When does the anomaly scan occur?
18-20+6 weeks
What points should be made when counselling about the progesterone only pill?
- Irregular vaginal bleeding is the most common problem
- Immediate protection if commenced up to and including day 5 of the cycle - otherwise use other protection for 2 days
When is screening done for gestational diabetes?
For women who have previously had gestational diabetes:
- OGTT should be done as soon as possible
- At 24-28 weeks if the first test is normal
Women with no risk factors:
- OGTT at 24-28 weeks
What are the risk factors for gestational diabetes?
- BMI >20
- Previous macrocosmic baby >4.5kg
- Previous gestational diabetes
- first degree relative with diabetes
- Family origin with high prevalence of diabetes
What is the management of primary dysmenorrhoea?
Primary = when theres no underlying pelvic pathology, usually appears within 1-2 years of menarche.
1st line: NSAIDs like mefanemic acid.
2nd line: COCP
What are the causes of secondary dysmenorrhoea?
Period pain that develops many years after menarche.
Usually starts 3-4 days before the onset of periods.
What are common causes of secondary dysmenorrhoea?
- Endometriosis
- Adenomyosis
- Pelvic inflammatory disease
- intrauterine devices (Copper coil)
- Fibroids
How is secondary dismenorrhoea managed?
All patients should be referred to gynaecology for investigation.
Which anti epileptics are relatively safe in pregnancy?
Lamotrigine, carbamazepine and levetiracetam.
Which anti epileptics are contraindicated in pregnancy?
Phenytoin, phenobarbitone and sodium valproate.
What is used for eclampsia (seizure) management?
IV magnesium sulphate.
When can expectant management be done in ectopic pregnancies?
Size <35mm
Asymptomatic
No foetal heartbeat
HCG <1,000
Monitor patient over 48 hours and if B HCG levels rise again or they become symptomatic, intervention is performed.
When is medical management done in ectopic pregnancies?
Size < 35mm
No significant pain
No fetal heartbeat
HCG <1500
Giving methotrexate and is only done if patient is willing to attend follow up
When is surgical management done for ectopic pregnancies?
Size >35mm
Pain
Visible fetal heartbeat
NCG >5000
What is the surgical management for ectopic pregnancy?
1st line:
- Laparoscopic Salpingectomy (removal of Fallopian tube).
- If no other risk factors for infertility
- Can be done open if the Fallopian tube is ruptured or there is haemodynamic instability.
2nd line:
- Salpingotomy
- Considered for women with risk factors of infertility (contralateral tube damage)
- 1 in 5 women require further treatment (medical or surgical management)
What is the Hb cut off for iron in pregnancy?
First trimester - <110g/L
Second/Third trimester - <105g/L
Postpartum - <100g/L
What is the first line investigation for postmenopausal bleeding?
Transvaginal ultrasound
Normal endometrial thickness is <4mm
Second line is a pipelle biopsy.
If pipelle is inconclusive - hysteroscopy with endometrial biopsy (dilation and curettage) can be done.
What is the treatment for endometrial cancer?
Surgery.
Progesterone therapy for old frail women.
What are the risk factors of pre-eclampsia?
Aged 40 years or older
Nulliparity
Pregnancy interval of more than 10 years
Family history of pre-eclampsia
Previous history of pre-eclampsia
Body mass index of 30kg/m^2 or above
Pre-existing vascular disease such as hypertension
Pre-existing renal disease
Multiple pregnancy
What are the signs of vulval cancer?
Hard painless Lump or ulcer on the labia major
Inguinal lymphadenopathy
Itching or irritation
What are the risk factors for vulval cancer?
> 65 years
HPV infection
Vulval intraepithelial neoplasia
Immunosuppression
Lichen sclerosis
What is the treatment for vaginal candidiasis?
Oral fluconazole
What are the most common ovarian cysts?
Follicular cysts
When should ovarian cysts be biopsied?
If they are complex (multi-loculated).
What is a simple ovarian cyst?
Thin walled
Non-loculated
<5cm in size
When should symptoms of IBS be investigated?
In women >50 with NEW symptoms of IBS in the last 12 months.
Measure serum CA-125
When should symptoms of IBS be investigated?
In women >50 with NEW symptoms of IBS in the last 12 months.
Measure serum CA-125
What is a raised CA-125?
35IU/mL or above.
Urgent ultrasound of abdomen and pelvis should be ordered.
Who should Ullipristal be used in caution with?
Patients with severe asthma.
What should be done in women with urinary incontinence?
A urinalysis - To rule out UTI and Diabetes mellitus.
How long should bladder retraining be done for?
A minimum of 6 weeks.
What test should be done if late decelerations are seen on CTG?
Fetal blood sampling - to assess for foetal hypoxia and acidosis.
when is a salpingectomy done over a salpingotomy?
If a women has no other risk factors: PID, contralateral tubal surgery and other risk factors for infertility.
What is the pattern of bleeding seen with the mirena coil?
Initially irregular bleeding later followed by light menses or amenorrhoea.
What are the signs and symptoms of HELLP syndrome?
Haemolysis
Elevated liver enzymes
Low platelets
Malaise
Nausea
Vomiting
Headache
Hypertension with proteinuria
Epigastric/upper abdominal pain
What are the 3 types of placenta accreta?
Accreta - chorionic villi attach to the myometrium rather than being restricted within the decider basalis
Increta - chorionic villi will invade through the myometrium
Percreta - Chorionic villi invade through the perimetric
If a semen sample is abnormal, when should a repeat test be done?
3 months later
How long does a male need to be abstinent for before performing semen analysis?
A minimum of 3 days and a maximum of 5 days.
When can diet and exercise be trialled in gestational diabetes?
if fasting plasma glucose is <7mmol/l
When should insulin be started regarding gestational diabetes?
if the patient has an initial fasting glucose >7mmol/l
when should metformin be started regarding gestational diabetes?
If 1-2 weeks of diet and exercise has not been able show an improvement.
What is the sequence of events regarding gestational diabetes?
Fasting glucose <7mmol -> 1-2 week trial of diet and exercise -> metformin trial -> Insulin trial
Fasting glucose >7mmol -> commence insulin
What type of insulin should be used for gestational diabetes?
Short acting
How many days after giving birth is a women not fertile for?
21 days
What is the treatment for obstetric cholestasis?
Ursodeoxycholic acid
Induction of labour at 37-38 weeks is common practice but may not be evidence based
What are the signs of obstetric cholestasis?
Intense pruritus - worse in palms, soles and abdomen
Clinically detectably jaundice in 20%
Raised bilirubin in >90%
What is the combined test for downs syndrome?
Done at 10-14 weeks.
- Ultrasound scan for nuchal translucency.
- Blood test for levels of Beta-hCG and PAPP-A.
What are the blood test results for Down syndrome?
PAPP-A low
Beta hCG raised
Thickened nuchal translucency
What is the quadruple test for Down syndrome?
Done if a women books later in pregnancy and is done between weeks 15-20
Tests: Alpha FetoProtein, unconjugated oestriol, hCG and Inhibin A
What are the quadruple tests for Down syndrome?
Low AFP
Low unconjugated oestriol
High hCG
High inhibin A
What are the contraindications to the injectable progesterone contraceptive?
UKMEC 4 - current breast cancer
UKMEC3 - Previous breast cancer
What are some of the adverse effects of the injectable progesterone contraceptive?
Irregular bleeding
WEIGHT GAIN
increased risk of osteoporosis
Fertility may take a longer time to return
What scale is used to screen for depression in the new mothers?
Edinburgh postnatal depression scale
Score >13 indicates a depressive illness of varying severity
what are risk factors for ectopic pregnancy
Smoking
damage to tubes - PID or surgery
previous ectopic
endometriosis
IUD
progesterone only pill
IVF
What is an indication of surgical management for ectopic pregnancy?
Presence of a foetal heartbeat
What is the complication of obstetric cholestasis?
Increased rate of stillbirth
What is the definition of premature ovarian insufficiency?
The onset of menopausal symptoms AND elevated gonadotrophin levels before 40 years.
What is the treatment of premature ovarian insufficiency?
Must be given HRT (both progesterone and oestrogen) until they are 51 (average age of menopause).
When should a women with PMB be referred to secondary care?
IF they are over 55 and are post-menopausal (more than 12 months without a period)
Which test is most accurate for diagnosing down syndrome?
Further screening test:
Non-invasive prenatal screening test
Diagnostic Tests:
Chorionic villous sampling - Done between week 11-13+7
Amniocentesis - done from week 15 onwards
What are the risk factors for placenta previa?
Multiparity
Multiple pregnancy
Previous cesarean section scar - embryos are more likely to implant on a lower segment scar
What is the normal foetal heart rate on CTG?
100-160
What are the only contraceptives that cna be used in active breast cancer?
Barrier method
IUD
ALL other forms of contraception are contraindicated
What are the signs of fibroids?
menorrhagia
abdo pain
urinary symptoms
subfertility
Iron deficiency anaemia
Usually regress after menopause
How are uterine fibroids diagnosed?
Transvaginal ultrasound
How are uterine fibroids treated?
Asymptomatic - no treatment (just monitor)
Medical:
GnRH agonists
Surgical:
Myomectomy
What is the treatment for gonorrhoea
IM Ceftriazone
What is the treatment for trichomonas vaginalis
Oral metronidazole
What is the treatment for bacterial vaginosis
Oral metronidazole
Which cancers are associated with BRCA1
Ovarian cancer
Breast cancer
WHat are the causes of primary post party haemorrhage?
Tone (uterine atony) - most common cause
Trauma (perineal tear)
Tissue (retained placenta)
Thrombin (clotting/bleeding disorder)
What is the management for a PPH
ABC Approach: Two peripheral cannulae, 14 gauge, lie woman flat, bloods including group and same, commence warm crystalloid infusion
Mechanical: Palpate uterine fundus and rub it to stimulate contractions, catheterisation to prevent bladder distention and monitor urine output
Medical: IV oxytocin
Surgical: Intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries or internal iliac arteries, hysterectomy.
What is the most common cause of secondary post partum haemorrhage?
Usually occurs between 24 hours - 6 weeks
Retained placental tissue
Endometritis
Which anti coagulant should be used in pregnancy?
Low molecular weight heparin
DOACs and Warfarin should be avoided
What is the treatment of eclampsia?
magnesium sulphate
treatment should continue for 24 hours after the last seizure or after delivery
*monitor respiratory rate and oxygen saturations
What is the treatment for mastitis?
First line:
- Simple analgesia and warm compress
If systemically unwell, nipple fissure present, symptoms not improving after 12-24 hours after effective milk removal or if culture indicates infection:
- Flucloxacillin for 10-14 days
What weight loss is normal for babies?
Weight loss between 7-10% is normal
Most babies return to birth weight within the 1st two weeks of life
What is the imaging done to diagnose an ectopic pregnancy?
Transvaginal ultrasound
How long must contraception be continued for if a women has gone through menopause?
If menopause is <50 - contraception should be used for 24 months.
If menopause is >50 - contraception should be used for 12 months.
What are the signs of ectopic pregnancy?
6-8 weeks of amenorrhoea
Lower abdominal pain
Vaginal bleeding
Shoulder tip pain
Dizziness, fainting or syncope
Symptoms of pregnancy - breast tenderness
Abdominal tenderness
cervical excitation
adnexal mass
Serum bHCG >1,500
What is the treatment for respiratory depression caused by magnesium sulphate?
Calcium gluconate
What staging system is used when determining management of cervical cancer?
FIGO Staging
What are the main symptoms of endometriosis?
Pelvic pain
Dysmenorrhoea
Dysparenuria
Subfertility
REDUCED ORGAN MOBILITY (FIXED UTERUS)
What is the gold standard investigation for endometriosis?
Laparoscopy
What is the treatment of endometriosis?
Symptomatic relief:
- NSAIDs and/or paracetamol
- COCP or progesterones
Secondary treatment:
- GnRH analogues (to induce menopause)
- Surgery
What contraceptive options are there for transgender people with a vagina on hormonal contraception?
Condoms OR Copper coil
What should be done if 1 pill is missed from the COCP?
Take the last pill even if it means taking two pills in one day and continue to take pills daily
No additional contraceptive protection needed
What should be done if two or more COCP pills are missed?
- Take 2 pills even if it means taking 2 in 1 day, leave any others.
- Women should abstain or use condoms until the pill has been taken for 7 days in a row
- If pills are missed in week 1, emergency contraception should be considered if she has had unprotected sex in the pill free interval or in week 1
- If pills are missed in week 2 after seven consecutive days of taking COC, theres no need for emergency contraception
- If pills are missed in week 3, she should finish the pills in her current back and start a new pack the next day, omitting the pill free interval
WHat is the most common cause of cord prolapse?
50% occur after an artificial rupture of membranes.
What are the criteria for diagnosing PCOS?
Rotterdam Criteria
2/3 of:
- Infrequent or no ovulation (oligomenorrhoea)
- Clinical or biochemical signs of hyperandrogegism OR elevated levels of total/free testosterone
- Polycystic ovaries on ultrasound or increased ovarian volume
What are the text book symptoms for placenta praaevia?
Painless vaginal bleeding after 24 weeks gestation
What are the features of a threatened miscarriage?
painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
the bleeding is often less than menstruation
cervical os is closed
complicates up to 25% of all pregnancies
WHat are the features of a missed (delayed) misscarriage
a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
cervical os is closed
when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
What are the features of an inevitable msiscarriage?
heavy bleeding with clots and pain
cervical os is open
What are the features of an incomplete miscarriage?
not all products of conception have been expelled
pain and vaginal bleeding
cervical os is open
what is the treatment for uterine fibroids?
If a uterine fibroid is less than 3cm in size, and not distorting the uterine cavity, medical treatment can be tried (e.g. IUS, tranexamic acid, COCP etc)
How long after should women treated for cervical intraepithelial neoplasia be given a smear?
6 months after treatment
What is post natal depression
It is important to ensure the symptoms do not last over 2 weeks which could be indicative of postnatal depression and would need further review. She also needs some reassurance and support, this option does not make any reference to providing ongoing support.
what antidepressant is used in post natal depression
Although sertraline is the right choice of antidepressant in breastfeeding individuals,
Who should be given aspirin in pregnancy
Women with risk factors for developing pre eclampsia should take 75-150mg of aspirin daily
from 12 weeks - delivery
What are the features of a vulval carcinoma
- 80% are squamous cell carcinomas
- usually present as a lump on the labia majora
- inguinal lymphadenopathy
- associated with itching, irritation and bleeding
- persistent, unexplained vulval skin lesion or lump
how is a post partum haemorrhage diagnosed
Digital vaginal examination SHOULD NOT be performed before ultrasound = it can provoke a severe haemorrhage
transvaginal ultrasond
often picked up on routine 20 week abdominal ultrasound
what is placenta praaevia
- a placenta lying wholly or partly in the lower uterine segment.
- pain is usually absent
what is placenta accreta
- when the placenta grows to deeply into the uterine wall
- severe bleeding after delivery
What is placental abruption
- when the placenta detaches from the uterine wall before delivery of the baby
- minimal vaginal bleeding, but severe abdominal pain.
what is vasa previa
- foetal blood vessels lie over the cervical os
- CTG will generally show foetal bradycardia as the foetal head is compressing its blood supply
what are uterine fibroids
Benign smooth muscle tumours of the uterus
what is the management used in uterine fibroids
asymptomatic:
- no treatment needed, can review periodically to monitor size and growth
menorrhagia:
- levonorgestrel IUS (can’t be used if theres uterine distortion)
- NSAIDs, TXA, COCP, oral progesterone, injectable progesterone
treatment to shrink/remove fibroids:
- GnRH agonists
- Surgical (myomectomy, hysteroscopy)
Which methods of contraception must be stopped at aged 50
COCP
Depo-Provera
How long after menopause should women continue to use contraception
Women <50 years - should continue contraception for 2 years after amenorrhoea
Women >50 years - should continue contraception for 1 year after amenorrhoea
What is the treatment of endometriosis
First-line:
- NSAIDs and paracetamol
If analgesia doesnt help:
- COCP or progesterones
Secondary care treatments:
- GnRH analogues
- Surgery
For women trying to concieve:
- Laparoscopic excision or ablation
when should cervical smear testing be done if due during pregnancy
Usually delayed until 3 months post-partum unless missed screening or previously abnormal smears
What are the two parts of the menstrual cycle
- Ovarian cycle - Development of a follicle and ovulation
- Endometrial cycle - Functional endometrium, thickens and sheds in response to ovarian activity
How long is the msntrual cycle
Can vary between 20-35 days.
The average is 28 days.
What is day one of the menstrual cycle
Day one is the first day of bleeding
When does ovulation occur
14 days before day one of the cycle (14 days before your bleed begins)
What are the phases in the ovarian cycle
- Follicular phase - corresponds to the menstrual and proliferative phases of the endometrium
- Luteal phase - corresponds to the secretory phase of the endometrium
What is the pre-ovulatory period
AKA - the follicular phase . This occurs before ovulation.
What are the hormones involved in menstruation
Hypothalamus - Secretes GnRH (gonadotropin releasing hormone)
This stimulates the anterior pituitary to secrete - FSH (follicle stimulating hormone) and LH (lutenizing hormone)
What are the role of the pituitary hormones
FSH and LH control the maturation of the ovarian follicles.
What is a follicle
A immature sex cell (primary oocyte) that’s surrounded by theaca and granulosa cells
What happens during the follicular phase
Follicles grow and compete against each other, they secrete oestrogen which is fed pack to the piutitary. It works as a negative feedback and tells the pituitary to secrete less FSH.
As a result of less FSH - some of the follicles then degress and die off. The follicle with the most receptors continues to grow and secrete oestrogen. It then acts as a positive feedback and this causes a surge in FSH and LH.
What happens during the menstrual phase
Occurs at the same time as the follicular phase
The old endometrial lining (functional layer) from the previous cycle is shed through the vagina.
This lasts an average of 5 days.
What happens during the proliferative phase
There is thickening of the endometrium in response to the rising oestrogen levels, theres also growth of the endometrial glands and emergence of spiral arteries.
The rising oestrogen also primes the cervical mucus to make it hospitable for sperm.
When is the optimum chance of becoming pregnant
Day 11-15 of an average 28 day cycle.
What occurs in the luteal phase
After ovulation, the follicle becomes the corpus luteum. The lutenised theca and granulosa cells (these cells have been exposed to lutenizing hormones).
These cells secrete oestrogen but also lots of progesterone.
They secrete more progesterone than oestrogen - this acts as a negative feedback which decreases the release of FSH and LH from the pituitary.
*PRogesterone is the dominant hormone in this phase - a rising progesterone with a falling oestrogen suggests that ovulation has occurred and helps make the endometrium receptive to a gamete.
What is the secretory phase
This is when the endometrium changes in response to the increased progesterone.
Spiral arteries grow the most and become coiled, mucus glands get bigger and produce more mucus.
After day 15 of the cycle the optimal window of fertilisation begs to close - the corpus luteum degenerates into the corpus albicans (non functional).
The corpus albicans doesnt make hormones so the hormone levels begin to decrease.
When the progesterone levels are at their lowest, the spiral arteries collapse and the functional part of the endometrium begins to shed off.
Which phase of menstruation varies
The follicular phase usually varies whereas the luteal phase is almost always 14 days before menstruation.
WHat are the menstrual cycle phases
Uterus:
- days 1-14: Menstrual and proliferative phase
- Days 15-28: Secretory phase
Ovaries:
- Follicular phase (first - can vary)
- Luteal phase (second - 14 days at the end)
what is the choice of VTE prophylaxis in pregnancy
Low molecular weight heparin
DOACs and warfarin are CI
how is postpartum thyroiditis treated
thyrotoxic phase - propanolol
hypothyroid phase - thyroxine
what is the treatment for mastitis
Flucloxacillin 10-14 days
which diabetic medications are safe when breast feeding
Metformin
Insulin
what are risk factors for ectopic pregnancy
damage to tubes (pelvic inflammatory disease, surgery)
previous ectopic
endometriosis
IUCD
progesterone only pill
IVF (3% of pregnancies are ectopic)
what are the signs of endometriosis
chronic pelvic pain
dysmenorrhoea
deep dysparenuria
subfertility
What are the signs of pelvic inflammatory disease
pelvic pain
fever
deep dysparenuria
vaginal discharge
dysuria
menstrual irregularities
cervicale xcitation
what are the signs and symptoms of fibroids
asymptomatic
menorrhagia
bulk-related symptoms (lower abdo pain, cramping during menstruation)
bloating
urinary symptoms
sub fertility
wehn can the COCP be started again after pregnancy
After 3 weeks IF NOT BREASTFEEDING
after 6 weeks IF BREASTFEEDING
what is mitttelschmerz
Usually mid cycle pain.
Often sharp onset.
Little systemic disturbance.
May have recurrent episodes.
Usually settles over 24-48 hours.
